Saturday, August 31, 2013

North Dakota Board of Pharmacy Quality-Related Events – Errors and Continuous Quality Improvement

By Howard C. Anderson, Jr, RPh
The Board, at its July 18, 2013 meeting, voted to move ahead with a rule to require a continuous quality improvement (CQI) program in all North Dakota pharmacies.
The Board already has a requirement in all of its telepharma- cies, central sites, its hospitals, and for sterile product preparation.
ND Vol. 2, No. 4
Many states have mandated reporting of errors that cause mortality or significant morbidity. The North Dakota Board feels this is too late in the process, as harm has already occurred.
It is the intent of the new requirement to focus on quality- related events (QREs), which are the precursors of errors (those that get out of the pharmacy’s hands and put the patient at risk).
The rule will require recording of QREs and analysis of them to identify places where changes can be made to prevent errors from occurring. Errors are also reported and serious analysis (gap analysis) is conducted to determine why we have a gap between our expected outcome (a perfect prescription or more importantly, a good patient outcome) and what actually occurred (an error of some kind resulting in a poor patient outcome).
The rule will include discovery protection (a lawyer cannot ask for your CQI report so he or she can find potential clients or reveal that you had six near misses to bolster his or her case before the judge or jury).
The rule will include a reference to reporting to a patient safety organization (PSO) to provide federal protection under the 2005 Patient Safety and Quality Improvement Act.
The North Dakota Pharmacists Association has a co-marketing agreement with a PSO and an excellent online CQI program. The Board will also have manual QRE recording forms on its Web site should you not choose to utilize an online CQI program. The Board will ask you to analyze your internally recorded QREs in lieu of the computer-assisted analysis.
Look for the rule hearing announcement, and of course the proposed rule will be published. 

quoted from the North Dakota Board of Pharmacy September 2013 Newsletter

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